2-Conflict of Interest Statement Form.pdf

This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for vendors responding to a Marion County contract opportunity related to Southwest Regional Water Reclamation Facility Operations & Maintenance Improvements. The form serves as a disclosure document to identify any potential conflicts of interest between the respondent and Marion County employees, public officers, or advisory board members. Respondents must indicate whether they or their principals have direct employment relationships, family connections, ownership interests exceeding five percent of business assets, or other prohibited relationships with County personnel. The form requires respondents to declare whether they will request an advisory board member waiver under Florida Statute 112.313(12) if applicable.

The County retains the authority to review all disclosed relationships against the Florida Ethics Code and may disqualify any vendor whose conflicts cannot be waived or exempted under applicable law. Completion of the form requires the company name, printed name of the respondent, and signature of an authorized representative. Failure to accurately disclose conflicts of interest may result in bid rejection or contract termination. This certification must be submitted as part of the bid package for the project consisting of installing three new Positive Displacement Blowers with associated electrical work, site preparation, instrumentation, and stormwater infrastructure at the Southwest Regional Water Reclamation Facility, along with decommissioning of existing equipment.